LTSS Integration in Health Plans and Health Systems
Long-Term Quality Alliance Annual Meeting
September 19, 2014
UnitedHealthcare’s Experience
• UnitedHealthcare
Community & State
serves more than 4
million members in
Medicaid and
Medicare programs
• We have
responsibility for
MLTSS in half of our
states
– Nearly all have
integrated
approaches to
LTSS
2
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Integrating LTSS in managed models
• Integrating social and functional
services that are at the core of
LTSS is fundamental to a
managed approach to LTSS
• The most effective models
integrate comprehensive benefit
design
• An ability to leverage benefit
flexibility is vital to an integrated
model
3
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Health plans don’t have to do it all
AAAs
Community resources should
be leveraged to maximize
resources and expertise
HHs
CILs
ACOs
The key is to not replace
fragmentation with more
fragmentation
4
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Our role as the integrator
• The health plan has a key role in establishing the foundation to
ensure integration
• Health plans should fill in gaps, remove barriers, and support
system transformation without unnecessarily replacing services
provided by experienced organizations
• Relationships between entities should be unique and leverage the
strengths of each organization
• Program payment – including downstream payments – should
ensure adequate funding to fuel innovation while aligning
incentives to improve member experience and outcomes
5
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
AETNA MEDICAID
LTSS Integration in Health Plans and Health Systems
Fragmented Expenditures for LTSS
$192 Billion
AETNA MEDICAID
Aetna Inc.
7
Aetna’s LTSS Integrated Care Goal
 De fragmentize care whenever possible
 Include management and support across the care
continuum
• LTSS
• HCBS → in-home or alternative residential facility
• Nursing Facility (NF)
• Medical
• Behavioral
• Coordination of non-covered services and supports
AETNA MEDICAID
Aetna Inc.
8
Integrated Care Strategy:
Person Centered Care
 Individualized case manager
 Face-to-face assessment
- Bio-psychosocial needs
- Personal preferences
- Identification of supports
- Condition specific assessment as needed
 Develop collaborative goals to support
- member needs
- personal preferences
- care provided by family/others (unpaid care)
AETNA MEDICAID
Aetna Inc.9 9
Guiding Principles for Person Centered
Integrated Care





Integrated, holistic approach
Support member in the least restrictive environment
Early intervention early when changes occur
Facilitate effective transitions between systems of care
Engage members early, recognizing strengths, capacities while
addressing critical physical, behavioral, environmental and
social needs
 Employ evidence based practices to create optimal outcomes
for members
 Provide access to a continuum of care, based on complexities
of individual member needs
 Support, not supplant informal supports (self directed care)
AETNA MEDICAID
Aetna Inc.
10
Aetna’s Integrated Person Centered Care Model
LTSS and
Behavioral
Health
Networks
Non-covered
Community
Resources
Medical
Networks
Case Manager
Quality
Management
Member /
Case &
Families
Caregivers
Pharmacy
Local
Transition &
Diversion
Programs
Grievances &
Appeals
Network and
Provider
Services
11
Opportunities to Mitigate Challenges
•
Early intervention for change in condition/circumstances
•
Member driven integrated care teams
•
Person centered plan of care
•
Back up/contingency plans
•
Risk mitigation agreements
•
Cost effectiveness studies
AETNA MEDICAID
Aetna Inc.
12
AETNA MEDICAID
Aetna Inc.
13
Barriers to ACO-LTSS Integration
Terrence A. O’Malley, MD
Massachusetts General Hospital
Partners HealthCare System, Inc.
What we have here…
Is a failure to Communicate
• PHS is not ready to listen to LTSS
• Focused instead on learning to be an ACO
–
–
–
–
Governance
IT integration
Primary Care infrastructure
Management of High Risk patients
• Not sure LTSS have anything to say
– No compelling data on the “value” of LTSS
– No quantitative impact on readmissions, VBP
– Most LTSS providers don’t know the cost of services
ACO patients who need LTSS
• Individuals with complex medical, behavioral, functional
and social needs
• High cost/High Risk: Duals, Medicare >6 chronic conditions,
Chronically mentally ill
• Receive care from multiple providers, in multiple sites
across prolonged episodes of care
• Require attention to transitions of care, longitudinal
coordination of care, medication management and referral
management
• Share a common pattern: High admission rates, High ER
use, High LTPAC use, High impact of the social determinants
of health such as housing, transportation, home based
supports.
Building a common IT platform
• IT integration of LTSS with the rest of health care
providers requires five components:
– An electronic highway that connects all parties
– Low cost access ramps to the highway for those
without EHRs and millions to spend
– Trucks to carry the information reliably between sites
– Cargo to put in the trucks, ie information, that is
valuable to the sites and standardized so it can be
used everywhere
– A compelling business case for this exchange
Putting the Pieces Together
• Highways: HIE build-out continues across the country
• On and Off Ramps: free, open source, Java based software
which allows non-EHR users to send and receive
standardized messages
• New trucks: Consolidated CDA, the required health care
data exchange standard stipulated in MU 2. A significant
improvement in flexibility
• High value cargo: standardized demographics, functional
status, cognitive status, nutritional needs, treatment plans,
medication lists, care plans
• The business cases: what does LTSS know that ACO
providers need to know? What do ACO providers know
that LTSS needs?